Ministry of Health



Gap Analysis of Specialist Palliative Care in New Zealand

Providing a national overview of hospice and hospital-based services

Disclaimer

While care has been used in the processing, analysis and extraction of information to ensure the accuracy of this report, neither the Ministry of Health nor Central Region’s Technical Advisory Services make any representations or warranties in respect of the accuracy or quality of the information, or accept responsibility for the accuracy, correctness, completeness or use of this report. The Ministry of Health and Central Region’s Technical Advisory Services shall not be liable for provision of any incorrect or incomplete information nor for any loss suffered through the use, directly or indirectly, of any information, product or service.

This report is copyright.

Report of the Ministry of Health with resource from:

Central Region’s Technical Advisory Services Limited (TAS)

Published in December 2009 by the

Ministry of Health

PO Box 5013, Wellington, New Zealand

ISBN 978-0-478-3393-2 (online)

HP 5025

This document is available on the Ministry of Health’s website:



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Acknowledgements

The authors would like to thank all the people who provided the qualitative and quantitative information on which this report is based, and those who provided valuable feedback and guidance in developing and piloting the gap analysis templates.

Your time, commitment and contribution are greatly appreciated.

Definitions

The following definitions are drawn from the draft service specification for specialist palliative care.

Specialist palliative care

Specialist palliative care is palliative care provided by those who have undergone specific training and/or accreditation in palliative care or medicine, and who are working in the context of an expert interdisciplinary team of palliative care health professionals. Specialist palliative care may be provided by hospices (community), hospital-based palliative care services, or paediatric specialist palliative care teams.

Specialist palliative care will increasingly be provided through services that meet standards developed nationally and that work exclusively in palliative care. Specialist palliative care practice builds on the palliative care provided by generalist providers and reflects a higher level of expertise in complex symptom management, spiritual support, psychosocial support, cultural support, and grief and loss support. Specialist palliative care provision works in two ways.

1. It works directly by providing direct management and support to people, their families and whānau where complex palliative care need exceeds the resources of the generalist provider. The involvement of specialist palliative care with any person and their family and whānau can be continuous or episodic depending on their assessed changing need. Complex need in this context is defined as a level of need that exceeds the resources of the generalist team: this may apply in any of the domains of care – physical, psychosocial, spiritual or cultural, for example.

2. It works indirectly by providing advice, support, education and training to other health professionals and volunteers to support their generalist provision of palliative care.

Generalist palliative care

Generalist palliative care is palliative care provided for those affected by life-limiting illness as an integral part of standard clinical practice by any health care professional who is not part of a specialist palliative care team. It is provided in the community by general practice teams, Māori and Pacific health providers, allied health teams, district nurses, residential care staff, community support services, and community paediatric teams. It is provided in hospitals by general adult and paediatric medical and surgical teams, as well as disease specific teams – for instance, oncology, respiratory, renal, intensive care and cardiac teams.

Some of these generalist providers, such as general practice teams, will have ongoing contact with a family throughout and following illness. Others, such as district nurses and hospital teams, will have episodic contact, depending on the needs of the person and their family and whānau.

Providers of generalist palliative care will have defined links with specialist palliative care team(s) for the purposes of support and advice, or in order to refer people with complex needs. They will also have access to palliative care education and learning to support their practice.

Contents

Acknowledgements iii

Definitions iv

Executive Summary viii

Introduction 1

Methodology 2

Data collection and analysis 2

Development of the templates 2

Pilot and national roll-out 3

Analysis of data 4

Limitations 4

The Need for Specialist Palliative Care 5

Mortality and cancer 5

Mortality and conditions other than cancer 6

Population aged over 65 years 6

Place of death 7

Service Overview 2007/08 8

Northern Region 8

Midland Region 9

Central Region 10

Southern Region 12

Paediatric palliative care 13

Workforce Overview 2007/08 14

Palliative care medical specialists 14

Palliative care specialist nurses 15

Requirements of the Service Specification 17

Referrals 17

Timeframe from referral to first contact 19

Inpatient units 19

Interdisciplinary teams 20

Communication with generalists 23

Community care 25

Day stay procedures 26

Day stay programmes 27

End of life care programmes 28

Grief and loss support 30

Education programmes for generalist and support services 32

Telephone advice and support to generalist providers 36

Linkages 39

Linkages outside own DHB 41

Staff education 42

Registrar training 43

Management of patient data 43

Reporting requirements 44

Response times 45

Equipment 46

Quality 47

Prescriptions 49

Income and expenses 50

Volunteers 50

Workforce 51

Service issues 55

Where to Next? 58

List of Tables

Table 1: Distribution of cancer deaths by Regional Cancer Network and District Health Board, 2007 5

Table 2: Population aged 65+ years by District Health Board and ethnicity, 2008 6

Table 3: Place of death of those who died of cancer, 2007 7

Table 4: Approximate population size served by each Northern Region hospice 9

Table 5: Approximate population size served by each Midland Region hospice 10

Table 6: Approximate population size served by each Central Region hospice 11

Table 7: Approximate population size served by each Southern Region hospice 12

Table 8: Total FTE palliative care medical specialists by region, 2007/08 14

Table 9: Total FTE palliative care nurses with postgraduate qualifications by region, 2007/08 16

Table 10: Summary of the staff involved and the aspects of care addressed at interdisciplinary meetings of hospice and hospital-based palliative care teams, 2007/08 22

Table 11: Summary of education provided by hospices and number of participants, 2007/08 34

Table 12: Hospice linkages with identified bodies, organisations and services, 2007/08 40

Table 13: Hospices and hospital-based palliative care services with auditable response times by type, 2007/08 45

Table 14: Number of auditable response times for hospices and hospital-based palliative care services, 2007/08 45

List of Figures

Figure 1: Number of inpatient beds for hospital-based palliative care services in Northern Region DHBs 8

Figure 2: Number of inpatient beds for hospital-based palliative care services in Midland Region DHBs 9

Figure 3: Number of inpatient beds for hospital-based palliative care services in Central Region DHBs 11

Figure 4: Number of inpatient beds for hospital-based palliative care services in Southern Region DHBs 12

Figure 5: Total FTE palliative care medical specialists per 100,000 by region and DHB, 2007/08 15

Figure 6: Total FTE palliative care nurses with postgraduate qualifications per 100,000 by region and DHB, 2007/08 16

Figure 7: Percentage of hospital-based palliative care services recording number of telephone and support services, 2007/08 38

Figure 8: Percentage of hospital-based palliative care services recording time spent on telephone and support services, 2007/08 38

Figure 9: Percentage of hospices with links to either district or regional palliative care/cancer networks and other regular meetings/forums, 2007/08 39

Figure 10: Availability of support services for hospital-based palliative care patients (rating expressed as a percentage), 2007/08 41

Figure 11: Adequacy of support services for hospital-based palliative care teams (rating expressed as a percentage), 2007/08 42

Executive Summary

Between January and June 2009 the Ministry of Health undertook a national stocktake or gap analysis to determine how close hospice and hospital providers of specialist palliative care services were to meeting the new draft service specification for specialist palliative care.

This Phase 1 report provides an overview of the current provision of specialist palliative care in New Zealand and highlights gaps against the draft service specification. The second phase of the project is to develop a costing model for specialist palliative care. This costing analysis is not presented in this report.

To obtain the data for this report, questionnaire templates for hospices and hospital providers of palliative care were developed in consultation with several palliative care personnel. The questionnaires were piloted before being rolled out nationally.

Main findings

The main findings with identified gaps are summarised below. This gap analysis confirmed the anecdotal evidence that there are wide variations in the provision of hospice and other specialist palliative care at both local and regional levels. Hospital services particularly are generally limited to nursing and medical services only. There are opportunities for sharing resources between services, such as between the hospice and the hospital-based palliative care service in the same region, to increase the level of access to specialist palliative care, particularly in terms of support for grief, loss and bereavement, for patients, families and whānau.

Workforce

Many of the gaps identified in this report are linked to workforce shortages. Some of these shortages relate to a national shortage of suitability trained staff (eg, medical specialists and nurses) and others to a lack of funding for a particular role (eg, end of life care co-ordinators).

Recruitment and retention of palliative care medical specialists is one of the biggest – if not the biggest – workforce issue for both hospices and hospitals. It is influenced by a shortage of suitability trained personnel and difficulties with providing competitive remuneration. For similar reasons a shortage of nurses with palliative care training is another key issue. Poor pay parity with multi-employer collective agreement (MECA) rates also makes it more difficult for hospices to recruit medical and nursing staff.

Other factors adding to the demand for palliative care medical specialists and nurses are: the opening of several new inpatient units; the requirements of the new tier two service specification regarding education and 24-hour, seven days a week (24/7) support; the growing and ageing population; increasing life expectancy; longer palliative survival; and patients with higher acuity and multiple co-morbidities leading to more complex symptom management. A shortage of palliative care medical specialists and nurses will affect the capacity of services to deliver key components of the new specialist service specification.

In addition, there is a lack of administrative support available to hospital-based palliative care teams. Amongst other consequences, such a shortfall exacerbates gaps around auditable response times and reporting requirements.

Palliative care teams within hospices are more multidisciplinary in their approach to care than hospital-based palliative care teams. The lack of a multidisciplinary approach in hospitals is a recognised gap that in turn results in gaps in delivery of components of the service specification, for example grief and loss support. There is an opportunity to work across the local area or region to ensure these services are provided to patients and their family and whānau.

Education and training, particularly programmes to upskill the available workforce, are key enablers to address workforce issues.

End of life care programmes

Across New Zealand, hospices and hospitals are at different stages with regard to the implementation of end of life care programmes. The Liverpool Care of the Dying Pathway (LCP) is the end of life programme that is most commonly applied, with national LCP’s support functions funded by the Ministry of Health. Some providers have rolled out LCP within their own organisation and into the community, others are at the pilot phase, and still more are waiting for funding; some are yet to determine their approach. No other end of life programmes have been introduced in New Zealand. Therefore the size of the gap in relation to end of life care programmes is variable.

Grief and loss support

All but one hospice appear to be equipped to meet the grief and loss support requirements of the draft service specification. Most (62%) employ or have access to trained staff, or both. Of these, 93% offer one-to-one follow-up grief and loss counselling and support to bereaved families and whānau.

Provision of grief and loss support represents a much greater gap for hospital-based palliative care services: only three of the eleven services provide such support after death to family and whānau of a patient. Fewer hospital-based palliative care services have dedicated bereavement resources. There may be an opportunity for hospital-based palliative care services to consider formalising links with a local hospice, and referring bereaved families and whānau to the hospice for follow-up grief and loss support. This approach is utilised on an ad hoc basis by one hospital-based palliative care service.

Education

Hospices appear well placed to deliver the education component of the draft service specification. Most (60%) have dedicated education staff, with one introducing the role during 2009. Many are looking at expanding the scope of education available to generalists.

Hospital-based palliative care teams currently do not have dedicated education staff and education is predominantly provided by the clinical staff. Often there are not enough resources to both attend to clinical demands and address the ongoing education needs of generalists.

There is an opportunity for greater collaboration between hospices and hospital-based palliative care services in providing education. Given that many hospices already deliver this component well, it seems feasible to share resources locally and establish a local education lead in palliative care. Further, there is an opportunity to share information nationally. The Hospice New Zealand education courses are those most commonly used in the sector, such that if Hospice New Zealand develops nationally consistent education courses for a wider audience, it will bring significant benefits to all specialist palliative care providers.

The transitioning nature of the generalist workforce poses challenges for both types of palliative care providers.

24-hour support

Provision of 24-hour, seven days a week specialist telephone advice to generalists is of a greater concern for hospital-based palliative care teams than hospices. All but one hospice currently have a mechanism in place to provide 24/7 advice to generalists and provide urgent telephone advice to them within one hour. Where the one hospice does not currently provide this service, its District Health Board (DHB) is investigating a 24/7 arrangement with another hospice. A similar arrangement involving three hospices is already in place in other parts of the country.

Provision of telephone advice outside normal working hours, particularly for new referrals, presents a gap for hospital-based palliative care teams. Telephone advice outside of normal working hours is currently not funded for seven out of the ten hospital-based palliative care teams answered.

Two hospitals have a link with their local hospices for telephone advice. Given that some hospices also have arrangements with other hospices, integrated collaboration within and between hospices and hospitals may be a way to address this gap.

Face-to-face consultation outside of normal working hours presents an even greater resource challenge. For all but one hospice, home visits by nurses are currently provided through a combination of hospice staff and district nursing services. Home visits by medical personnel are currently provided by either general practitioners or medical specialists for all but three hospices. However these arrangements are not always ideal for either patient or staff.

Only two hospitals currently provide on-site consultation outside of normal working hours. (Two more do so occasionally.)

Paediatric palliative care

In some instances, the small number of paediatric patients seen by some services has meant that these services have not developed clear referral guidelines for children or formal links with paediatric services. At the same time, because these services see very few children, they will be less experienced in addressing the specific needs of children as specialist providers of paediatric care and it is therefore imperative that appropriate referral guidelines and linkages are in place to enable equitable delivery of paediatric palliative care across New Zealand.

The draft service specification states:

In meeting the palliative care needs of children and adolescents the paediatric specialist palliative care team at Starship Hospital Auckland is the national resource service. It is available to collaborate with the patient’s primary paediatric team, any local paediatric palliative care services/support and, if necessary, the local adult specialist palliative care services.

Other palliative paediatric services include Rainbow Place and True Colours in Waikato; and Skylight, a national service that provides specialised support to children, young people and their families and whānau through change, loss, trauma and grief.

IT systems

Providers of palliative care require appropriate information technology (IT) tools to both manage the day-to-day running of the service and meet reporting requirements.

The Palcare patient management system has been developed specifically for palliative care and many hospices are currently implementing it (10 hospices) or plan to implement it (six hospices) or are investigating it (two hospices). Hospices using electronic Palcare should be reasonably well placed to address their operational needs. Further, these hospices are likely to meet the future service specification reporting requirements. Although these requirements have not been finalised, they are unlikely to involve more reporting than is required under the version released in February 2008. Whether sufficient staff resources are available to gather and enter the relevant data is another issue.

There are likely to be IT-related gaps between now and the implementation of Palcare (where applicable) and in those hospices without Palcare or an alternative patient management system.

The requirement of adequate IT systems poses a gap for several hospital-based palliative care teams, despite some having links to their hospital IT systems. Improvements to these systems or extension of the data collected are dependent on organisational resources and prioritisation against other organisational projects.

Ineffective IT tools in both hospice and hospital-based palliative care environments will impact on staff time which might be better utilised in other ways.

Auditable response times

Auditable response times represent a gap for some service providers. Only 15 of the hospices (56%) and three of the hospital services (30%) are currently able to provide auditable response times for all four situations set out in the questionnaire.

In particular, many providers cannot audit the response time for urgent telephone advice to generalists. The capacity to audit response times is linked to two issues already identified – IT and administrative support. Also contributing to this gap are issues around policies, staff training and compliance.

Opportunities for action

As identified above, there are key opportunities for action by palliative care providers at both local and regional levels to ensure each DHB district delivers specialist palliative care services to its population that meet the requirements of the draft service specification. These opportunities for action are founded on collaboration between providers, with a focus on an integrated service model for the patient, which is centred on the patient and their family and whānau. Some districts and regions already provide this kind of model in some aspects, such as in the provision of 24/7 telephone advice, shared palliative care medical resources, and referrals to a hospice for grief and loss support to bereaved families and whānau. In an economically constrained environment, the challenge is for funders and providers to continue to collaborate and develop sensible and appropriate local and regional solutions.

Introduction

Over the last three years the Ministry of Health (‘the Ministry’) has been working with the palliative care sector (both hospice and hospital-based palliative care services) to develop a revised draft service specification for specialist palliative care in New Zealand.

Once the service specification is ratified, the level of service described will become the minimum level of service required in the sector. The draft service specification was released to palliative care providers in February 2008 along with $2 million in funding. While several hospices and hospital-based palliative care teams were working towards incorporating all or some of the components of the draft service specification, the Ministry undertook a national stocktake or gap analysis to determine how close services in their current form were to meeting this new service specification.

The objectives of the gap analysis were to source:

1. qualitative-based assessment of services against the draft service specifications

2. quantitative financial and patient-level data.

The data were collected to:

1. present an overview of the current state of service provision in hospice/specialist palliative care on a consistent basis regionally using data from the 2007/08 financial year

2. identify specific gaps in service provision relative to the draft service specifications

3. determine the resources required to implement the draft service specification

4. develop the costing models to inform the development of the purchase unit codes for the draft service specification

5. inform the joint Ministry of Health and District Health Board Service Specification Programme Executive and assist with the ratification of the draft service specification.

This report presents Phase 1 of the results of the largely qualitative service analysis and provides a national overview of where specialist palliative care delivery is at using data from the 2007/08 financial year. Phase 2 of the gap analysis will address the resources required, and develop funding models for the draft service specification.

This report has not attempted to address the quality of specialist palliative care providers, nor does it make any recommendation as to the appropriateness of the level of service provided. It concentrates instead on the aspects of services as articulated in the draft specialist palliative care service specification.

It should be noted that the ability to collect data (patient activity level) was significantly limited by a number of factors including information technology (IT) infrastructure and the time lag between the first release of the draft service specification to the sector and the requested timeframe for data. Thus there was large variability in service providers’ ability to submit the data requested. In view of these limitations, this report is intended as a general guide rather than as a source of definitive data on the palliative care sector. The information it presents, like that to be used in Phase 2 of the gap analysis, was previously not available and will contribute to the development of more accurate work nationally.

Methodology

The project’s scope was established and objectives were defined. The project team consisting of Ministry of Health staff and staff resource from Central Region’s Technical Advisory Services agreed the methodology and timeframe. Expertise was drawn from across the specialist palliative care sector to support the process.

Data collection and analysis

The project team was responsible for identifying the data required for collection. Its decisions were based on the aims and objectives of the gap analysis (see introduction), and the draft service specification for specialist palliative care. It was agreed that the data would be collected over the financial year 1 July 2007 to 30 June 2008, as it was the most recent complete financial year at the time of the data collection. It was agreed that in some instances where provider data were unavailable from that period, more recent data or data related to a more limited timeframe (eg, six months) would be permissible, on the grounds that the priority was to gain data at a basic level for each provider.

Development of the templates

Separate templates were developed for hospices and hospital-based palliative care services. For each service, three templates were developed: a qualitative questionnaire in Microsoft Word, a quantitative questionnaire in Microsoft Word, and a quantitative patient-level data request in Microsoft Excel. This development phase took place over a month, from late January to late February 2009.

The first (Word) template was developed by the project team in consultation with experts from across the specialist palliative care sector. In developing the qualitative questionnaire, key requirements of the draft service specification were rephrased as questions. Answer options involved tick boxes along with an ‘other’ answer option. Some topics not specifically from the service specification were also included in the questionnaire. Open-ended questions were limited. Providers were asked to supply information on the current state of their service (during the financial year of data collection). The questionnaire was initially developed using tick and text box functions in Microsoft Word which required macros to be enabled. A non-macro version was later developed.

The second (Word) and third (Excel) templates were both quantitative in nature. The project team developed the second template; Ministry of Health staff developed the third template and will complete the costing work. Both templates were developed in consultation with the specialist palliative care sector and were largely based on data required to inform the costing model.

It is noted that the financial year chosen, 2007/08, includes months prior to the release of the draft specification in February 2008. In addition the patient-level data requested differed to the data currently required to be reported to the Ministry of Health. If services were unable to provide the data for the requested financial year, they were asked to provide data for an alternative (clearly stated) time period. These factors will be taken into account in the modelling methodology.

Although the themes were similar, the specific questions asked in the hospice and hospital questionnaires differed from each other to reflect the different nature of their respective service models. Furthermore the development of the hospital questionnaire was slightly behind that of the hospice questionnaire and some minor changes to the hospital questionnaire were made after the hospice questionnaire had rolled out nationally. More detail on these differences is given in the relevant sections in this report.

The gap analysis templates for hospices were sent to 28 hospices throughout New Zealand; the quantitative templates were received back from all 28, and the qualitative template from 27. All the qualitative and quantitative templates were received back from the 10 hospital-based palliative care services to which they were sent, and a partially complete template from one other hospital.

Note that an additional template for District Health Board (DHB) Planning and Funding teams was later developed to support the above data collection. Detailed results from this template will not be reported on but will be used to inform the gap analysis process.

Pilot and national roll-out

Before they were piloted, the first two hospice templates were reviewed by Hospice New Zealand. The hospice templates were then piloted in four hospices over two weeks in late February and early March 2009 and rolled out nationally in mid-March 2009. The hospital templates were piloted by two hospital-based palliative care teams over three weeks in late February and early March, and then rolled out nationally in late March 2009.

Documentation accompanying the pilot and national roll-out of the gap analysis included a general information sheet, a data dictionary, a ‘How to complete the Excel template’ document, a document explaining how to enable macros, and a copy of the February 2008 draft tier two service specification.

Hospices and hospitals that were to receive the gap analysis templates were identified by the Ministry of Health. Prior to national roll-out, the Ministry informed hospices and hospital-based palliative care teams of the upcoming gap analysis, and Hospice New Zealand also communicated with hospices regarding the analysis. Hospices and hospitals were both given five weeks to complete the templates. Follow-up continued until June 2008. The Ministry was available throughout the process to answer any questions from providers.

Analysis of data

On receipt of the first two (Word) templates from the respondents, the responses were checked for any inconsistencies, missing data and incorrectly interpreted questions and any issues were communicated back to the hospital or hospice for their response. More follow-up was required for hospices than hospitals due to the more complex nature of their questionnaire. The most common reasons for follow-up with hospices were to match up the education courses identified in the qualitative with those identified in the quantitative templates; to clarify an unclear nursing-related question; and to check totals against individually reported figures for workforce salaries, income and expenses. Occasionally a respondent did not answer a certain question, which is noted in the results where applicable.

The project team entered the data from the first two templates into Excel for analysis and identified common themes from the qualitative responses. In this Phase 1 gap analysis report, only some of the quantitative data are reported.

Data checking and analysis associated with the patient-level data request and other costing data form Phase 2 of the gap analysis.

Limitations

The limitations of this gap analysis include the following.

1. Terms were not uniformly defined (eg, what constitutes a ‘care co-ordination’ event or ‘community care’) although definitions were provided. Providers differed in the way they used some terms. Further, the way in which activities were measured in different services limits the comparisons that can be made between services. The Ministry of Health is currently developing proposed minimum data sets for specialist palliative care, which will allow activities and services to be defined consistently, and provide national standardisation.

2. Providers varied in their responses regarding the level of postgraduate education in the palliative care workforce. Levels of training and expertise (eg, certificate, diploma, master’s degree) vary across the disciplines, mainly nursing, and across providers. Promisingly, however, a significant number of the workforce has undertaken postgraduate training of some sort.

3. Since the 2007/08 financial year for which the data are reported, in some instances new services have been developed and staffing levels have changed. The qualitative template included an opportunity for providers to identify proposed changes to their service or staffing.

4. Although the project team experienced an extremely high level of co-operation and was able to garner data sets from all providers, the lack of IT infrastructure and previous data collection made it necessary to extrapolate some of the data from other services. This information is required for Phase 2 of the gap analysis.

5. The report provides information on the structure of services and in Phase 2 on the activity levels. This information does not in itself provide a measure of quality.

The Need for Specialist Palliative Care

This section provides a range of data on cause of mortality, the ageing population and place of death that indicate the extent to which specialist palliative care may be needed in New Zealand.

Mortality and cancer

Cancer mortality data for the 2007 calendar year were sourced on 16 September 2009 from the mortality collection (part of the National Collections). In 2007 there were 8487 deaths from cancer. Table 1 outlines the distribution of cancer deaths by region and District Health Board.

Table 1: Distribution of cancer deaths by Regional Cancer Network and District Health Board, 2007

|Regional Cancer |Deaths of those aged 15 and over with cancer |District Health Board |Deaths of those aged 15 and over with|

|Network |as an underlying cause for the region | |cancer as an underlying cause |

|Northern |2,585 |Auckland |704 |

| | |Counties Manukau |661 |

| | |Northland |389 |

| | |Waitemata |831 |

|Midland |1,493 |Bay of Plenty |511 |

| | |Lakes |228 |

| | |Waikato |754 |

|Central |2,151 |Tairawhiti |97 |

| | |Taranaki |298 |

| | |Capital and Coast |468 |

| | |Hawke’s Bay |365 |

| | |Hutt Valley |289 |

| | |MidCentral |379 |

| | |Wairarapa |95 |

| | |Whanganui |160 |

|Southern |2,258 |Canterbury |1,044 |

| | |Nelson Marlborough |306 |

| | |Otago |453 |

| | |South Canterbury |163 |

| | |Southland |225 |

| | |West Coast |67 |

Mortality and conditions other than cancer

Specialist palliative care services also need to be made available to those dying of conditions not related to cancer. From the data within the mortality collection, it was not possible to gauge with any certainty the percentage of non-cancer deaths that would have benefited from specialist palliative care.

Population aged over 65 years

The ageing population will increase the prevalence of both cancer and non-cancer conditions that result in death. Correspondingly there is likely to be a need for incremental growth of specialist palliative care. Table 2 shows the spread of the ageing population across District Health Boards, breaking down this information by ethnicity.

Table 2: Population aged 65+ years by District Health Board and ethnicity, 2008

|Regional Cancer |District Health Board |Population aged |Population aged |Population aged |Population aged 65 years |

|Network | |65 years and over |65 years and over |65 years and over |and over (European /Other)|

| | | |(Māori) |(Pacific | |

|Northern |Auckland |42,000 |1,500 |2,980 |37,520 |

| |Counties Manukau |42,960 |2,490 |4,440 |36,030 |

| |Northland |23,400 |3,140 |110 |20,150 |

| |Waitemata |58,750 |1,640 |1,530 |55,580 |

|Midland |Bay of Plenty |33,680 |2,840 |110 |30,730 |

| |Lakes |12,690 |1,740 |110 |10,840 |

| |Waikato |46,230 |3,370 |450 |42,410 |

|Central |Tairawhiti |5,595 |1,340 |45 |4,210 |

| |Taranaki |16,435 |880 |35 |15,520 |

| |Capital and Coast |30,290 |1,030 |1,160 |28,100 |

| |Hawke’s Bay |21,930 |1,780 |180 |19,970 |

| |Hutt Valley |16,650 |710 |500 |15,440 |

| |MidCentral |23,960 |1,240 |120 |22,600 |

| |Wairarapa |6,860 |320 |30 |6,510 |

| |Whanganui |10,255 |840 |35 |9,380 |

|Southern |Canterbury |67,360 |1,390 |360 |65,610 |

| |Nelson Marlborough |20,945 |580 |55 |20,310 |

| |Otago |27,460 |450 |100 |26,910 |

| |South Canterbury |10,295 |160 |5 |10,130 |

| |Southland |14,675 |600 |55 |14,020 |

| |West Coast |4,730 |150 |– |4,580 |

Source: Data accessed from population projection for 30 June 2008 and sourced from Statistics New Zealand standard populations which are derived from the 2006 Census results.

Place of death

There is a relative lack of good quality data on the place of death of those who die in New Zealand, making it difficult to directly match cause of death with place of death. Table 3 below shows the percentage of the population who died of cancer in each of the categories for which place of death is recorded: public hospital, private hospital (including hospices with inpatient beds but excluding rest homes where the rest home is the individual’s usual place of residence) and other.

Table 3: Place of death of those who died of cancer, 2007

|Facility type |Deaths of those aged 15 and over with cancer as an |

| |underlying cause |

|Public hospital |26.3% |

|Private hospital |36.8% |

|Other |36.9% |

Source: Data accessed for the 2007 calendar year on 16 September 2009 from the mortality collection (part of the National Collections).

Service Overview 2007/08

This section presents a national overview of palliative care services in New Zealand. It sets out the location of hospices and hospital-based palliative care services in each region, with more detailed analysis by District Health Board, along with the population served by each hospice. Regional Cancer Networks are used as the regional boundaries because many services connect via the Palliative Care and Cancer networks of the regional cancer networks. Specific hospices and hospitals are named only in this section to provide context. For the remaining sections of this report they are not identified by name except in a few cases to again set out the context of current and future services.

Northern Region

The Northern Region is comprised of Northland, Waitemata, Auckland and Counties Manukau DHBs.

Figure 1: Number of inpatient beds for hospice-based palliative care services in Northern Region DHBs

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Hospices

The Northern Region, with 10 hospices, has the largest number of any region. Northland DHB has one tertiary regional hospice and three smaller hospices operating in a hub and spoke model. Within the Waitemata DHB there are three hospices; within Auckland DHB there is one hospice; and within Counties Manukau DHB there are two hospices. Table 4 below shows the population range that each hospice serves.

Table 4: Approximate population size served by each Northern Region hospice

|Population range |Number of hospices |Hospice name(s) |

|< 50,000 |3 |MidNorthland (Northland DHB), Far North (Northland DHB), Kaipara (Northland |

| | |DHB) |

|50,000–99,999 |2 |Franklin (Counties Manukau DHB), Hibiscus Coast (Waitemata DHB) |

|100,000–199,999 |1 |North Haven* (Northland DHB) |

|200,000–399,999 |2 |North Shore (Waitemata DHB), West Auckland (Waitemata DHB) |

|400,000+ |2 |Mercy (Auckland DHB), South Auckland (Counties Manukau DHB) |

Note: * The local population served by North Haven hospice is 76,000 but its regional population is 150,000.

Hospitals

The Northern Region has three hospital-based palliative care teams, located at North Shore Hospital, Auckland City Hospital, and Middlemore Hospital. North Haven hospice are contracted to provide a hospital-based palliative care service in Whangarei Hospital.

Midland Region

The Midland Region is comprised of Waikato, Bay of Plenty, and Lakes DHBs.

Figure 2: Number of inpatient beds for hospice-based palliative care services in Midland Region DHBs

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Hospices

The Midland Region has five hospices. Within the Waikato DHB there is one hospice (excludes Rainbow Place and True Colours both providing paediatric services; and Tokoroa Hospice which is not a specialist service); Bay of Plenty and Lakes DHBs have two hospices each. At the time of data collection, Waikato Hospice had no inpatient beds but this situation is due to change shortly. Table 5 below shows the population range that each hospice serves.

Table 5: Approximate population size served by each Midland Region hospice

|Population range |Number of hospices |Hospice name(s) |

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